Job Information
Actalent Case Manager- Utilization Review in Oklahoma City, Oklahoma
Hiring for Case Manager- Utilization Review
Job Description
Care Managers perform integrated case management (CM) and disease management (UM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians. Care Managers determine, develop and implement a plan of care based on accurate and comprehensive assessment of the member’s needs. Care Managers apply detailed knowledge of established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.
Responsibilities:
• Determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member’s needs.
• Apply detailed knowledge of FEP PPO established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.
• Work with complex cases, promoting the delivery of quality, cost-effective health care services based on medical necessity and contractual benefits.
• Provide guidance to the provider network via telephone triage.
• Perform effective discharge planning and collaborate with member support system and health care professionals involved in the continuum of care via phone/computer work.
• Make referrals to Quality Management and Appeals and Grievance Department via computer and virtual meetings.
Hard Skills
Licensed RN
Acute care experience or surgery experience
Case Management Experience
Knowledge of MCG Medical Necessity criteria
Understanding of Medical Necessity Review
Work Site
This is a fully on-site position in Oklahoma City, Oklahoma City.
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
Diversity, Equity & Inclusion
At Actalent, diversity and inclusion are a bridge towards the equity and success of our people. DE&I are embedded into our culture through:
Hiring diverse talent
Maintaining an inclusive environment through persistent self-reflection
Building a culture of care, engagement, and recognition with clear outcomes
Ensuring growth opportunities for our people
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.